Mental Health Advance Directives (MHADs) are an emerging method of treatment planning for adults with serious and persistent mental illness. MHADs describe preferences for services and supports, documenting these preferences in advance of acute symptomatology, when a consumer cannot articulate these preferences themselves. Despite considerable support and use of MHADs within community mental health there has been very little research on the topic. The aims of the study are: (1) Describe MHAD execution processes: (a) Who is interested in executing a MHAD?-rates and predictors; (b) Who can successfully execute MHADs?-rates and predictors; (c) How do consumers and service providers view MHADs? (2) Describe steps leading to MHAD impact on services during mental health crises: (a) Does the AD-Maker MHAD differ from standard crisis plans? (b) Whether and in what circumstances are MHADs used? (c) What are barriers and facilitators to using MHADs during mental health crises? The sample will be drawn from adults with at least two psychiatric hospitalizations in the previous two years who are receiving outpatient community support services at two community mental health centers (CMHCs) in Washington state. Data sources include consumer and case manager interviews and chart reviews following MHAD-triggering events over two years. Multi- stakeholder focus groups will be conducted for Aim 2c. Electronic information systems will provide demographic, diagnostic, level-of-functioning, outpatient commitment status and service utilization data.